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Burnett County Office of Zoning Administrator W CD o Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD 1: <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> C � B di C o <br /> .. .. . . . . . ..................................................................... ........................................................................ ............OWNER (ple e print) CONTRACTOR or SURVEYOR or AGENT V <br /> RESS <br /> .... ....1`........................................................... T ................U....... ` ...................................... <br /> ADD ,, ADDRESS <br /> .�..'�..�. :�s.....5...`���.... ........�'.�. .°` �. ....... ............�.:.s....5 � <br /> . / <br /> ADDRESS ADDRESS <br /> e)3 r% J <br /> Q.. ........... ........................................ ..... ......................... ............. <br /> PHO PHONE <br /> PLUMBER WELL DRILLER `\ <br /> .:5...,.... <br /> ADDRESS ADDRESS.......................�...C........�........... � <br /> .... . � O <br /> 3 <br /> 0 <br /> ........................................................................................... Z o 1' <br /> ........................................ 1 r< <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° ` <br /> 1. Work: No. Bathrooms (, <br /> 2. New Building Details F� o w <br /> New Building No. Bedrooms ......... L <br /> ....... Type of Construction: <br /> Addition ...,•,•... Septic Tank Size Gals. .......... �; <br /> .. <br /> i <br /> Sanitary : <br /> Y ....?�. Size ......... ..., ft. x .. ....... .. ft. 7: <br /> Filling ...•.....• Height�.»»?.�... Stories ...�. 4a. Absorption Field Site: ro: <br /> Area d`� �� Soil Type .................................... �: r <br /> Moving .... ..... o <br /> Grading <br /> Slope ..............................I........... ^� �• <br /> Perc. Rate ................................... <br /> Mobile Home 3. Use (describe exactly, 1 family r <br /> Privy hom arage, rp gtel, e Dry Well <br /> Well Seepage Trench <br /> .......... ..... ........ ........ I................ <br /> Subdivision Privy .......... I r <br /> ........................ .......................... ii <br /> Seepage Bed .......... Q <br /> ---------------------------------------------------------------------- ° <br /> Cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- jw a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o c <br /> o' <br /> -------------------------------------- <br /> -------------------------------- <br /> .i 1 c = <br /> 5. Lo ize: Q Fig. A. 6. Location: <br /> S?.. a.. ft. x .............. ft. — ..4?... atiQp sq. ft. Cn <br /> w K ` <br /> J <br /> CD <br /> 0 <br /> N O O= <br /> I = 13 <br /> 0 <br /> 7 <br /> ja a _-------- CD <br /> -n <br /> o <br /> CD <br /> _ <br /> CD <br /> cp cn r 9 o <br /> m C n '. c m <br /> Q, <br /> oH; C : < cn <br /> N� ^/ Z oO fD <br /> ........................................................................... ...................................... E <br /> Signature of ox Agent Date — <br /> �a�9�" <br /> Remarks .. .. .�.�-..� ... .. .. ..............�io 9,'�........................................................................................................................... C, <br /> Co <br /> 61 ' <br /> ........................................................................................................................................................................................ <br /> ...................................... <br /> .. � <br /> ......................... . .... <br /> Inspection Date ....................................... lha?,�,1 Cd u i o 6 6 6 6 6 m <br /> Zoning Admin stY rator A•J <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> )efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />